Maternal risk factors associated with inadequate testing and loss to follow-up in infants with perinatal hepatitis C virus exposure

Best practices for hepatitis C linkage to care in pregnant and postpartum women: perspectives from the Treatment In Pregnancy for Hepatitis C Community of Practice

There is an increasing burden of hepatitis C virus among persons of reproductive age, including pregnant and breastfeeding women, in many regions worldwide. Routine health services during pregnancy present a critical window of opportunity to diagnose and link women with hepatitis C virus infection for care and treatment to decrease hepatitis C virus-related morbidity and early mortality. Effective treatment of hepatitis C virus infection in women diagnosed during pregnancy also prevents hepatitis C virus-related adverse events in pregnancy and hepatitis C virus vertical transmission in future pregnancies. However, linkage to care and treatment for women diagnosed in pregnancy remains insufficient. Currently, there are no best practice recommendations from professional societies to ensure appropriate peripartum linkage to hepatitis C virus care and treatment. We convened a virtual Community of Practice to understand key challenges to the hepatitis C virus care cascade for women diagnosed with hepatitis C virus in pregnancy, highlight published models of integrated hepatitis C virus services for pregnant and postpartum women, and preview upcoming research and programmatic initiatives to improve linkage to hepatitis C virus care for this population. Four-hundred seventy-three participants from 43 countries participated in the Community of Practice, including a diverse range of practitioners from public health, primary care, and clinical specialties. The Community of Practice included panel sessions with representatives from major professional societies in obstetrics/gynecology, maternal fetal medicine, addiction medicine, hepatology, and infectious diseases. From this Community of Practice, we provide a series of best practices to improve linkage to hepatitis C virus treatment for pregnant and postpartum women, including specific interventions to enhance colocation of services, treatment by nonspecialist providers, active engagement and patient navigation, and decreasing time to hepatitis C virus treatment initiation. The Community of Practice aims to further support antenatal providers in improving linkage to care by producing and disseminating detailed operational guidance and recommendations and supporting operational research on models for linkage and treatment. Additionally, the Community of Practice may be leveraged to build training materials and toolkits for antenatal providers, convene experts to formalize operational recommendations, and conduct surveys to understand needs of antenatal providers. Such actions are required to ensure equitable access to hepatitis C virus treatment for women diagnosed with hepatitis C virus in pregnancy and urgently needed to achieve the ambitious targets for hepatitis C virus elimination by 2030.

Factors Associated With Perinatal Hepatitis C Screening Among Exposed Children: 2016-2020

BACKGROUND AND OBJECTIVES

Children perinatally exposed to hepatitis C virus (HCV) should be screened for infection, yet testing rates are low. Clinical perinatal HCV testing recommendations vary and may contribute to poor completion. This study examines pediatric care factors associated with perinatal HCV testing completion.

METHODS

A cohort of people living with HCV in Philadelphia, Pennsylvania, who delivered a live birth in 2016 to 2020 and their children were followed by the Philadelphia Department of Public Health. The association of completion of HCV screening with pregnant/postpartum person demographics, pediatric care factors, and testing policy were retrospectively explored. χ2 and multivariable logistic regressions were used.

RESULTS

HCV-positive pregnant people gave birth to 457 children of whom 307 (67.2%) were tested for HCV according to recommendations and 79 (17.2%) were inadequately tested. Children were more likely to be tested if born to a pregnant person with HIV coinfection (P = .007), if they were always on schedule for vaccinations (P < .001), and if they attended the 18-month well visit (P < .001). Completion rates varied significantly by pediatrician's testing policy: 90.9% tested if the policy was for 2 months, 79.6% if 2 to 12 months, 61.9% if 12 months, and 58.5% if 18 months of age (P < .001).

CONCLUSIONS

Timing of perinatal HCV testing policies was significantly associated with testing completion rates. Testing at 2 months was associated with far better HCV testing completion than other strategies, regardless of birthing person and pediatrician factors. These findings suggest routine HCV testing of children perinatally exposed to HCV is best achieved in the first year of life.

Acceptability of hepatitis C screening and treatment during pregnancy in pregnant women in Egypt, Pakistan, and Ukraine: A cross-sectional survey

Chronic hepatitis C (HCV) in women of childbearing age is a major public health concern with ∼15 million women aged 15-49 years living with HCV globally in 2019. Evidence suggests HCV in pregnancy is associated with adverse pregnancy and infant outcomes. This includes ∼6% risk of infants acquiring HCV vertically, and this is the leading cause of HCV in children globally. However, few countries offer routine universal antenatal HCV screening, and direct-acting antivirals (DAAs) are not approved for pregnant or breastfeeding women although small clinical trials are ongoing. We conducted a survey of pregnant and postpartum women in 3 high HCV burden lower-middle-income countries to assess the acceptability of universal antenatal HCV screening and DAA treatment in the scenario that DAAs are approved for use in pregnancy. Pregnant and postpartum women attending antenatal clinics in Egypt, Pakistan, and Ukraine were invited to complete a survey and provide demographic and clinical data on their HCV status. Among the 630 women included (n=210 per country), 73% were pregnant and 27% postpartum, 27% were ever HCV antibody or PCR positive. Overall, 586 (93%) reported acceptability of universal antenatal HCV screening and 544 (88%) would take DAAs in pregnancy (92%, 98%, and 73% in Egypt, Pakistan, and Ukraine, respectively). Most said they would take DAAs in pregnancy to prevent vertical acquisition and other risks for the baby, and a smaller proportion would take DAAs for maternal cure. Our findings suggest that should DAAs be approved for use in pregnancy, the uptake of both HCV screening and DAA treatment may be high in women living in lower-middle-income countries.

Frequency of Children Diagnosed with Perinatal Hepatitis C, United States, 2018-2020

We describe hepatitis C testing of 47 (2%) of 2,266 children diagnosed with perinatal hepatitis C who were exposed during 2018-2020 in 7 jurisdictions in the United States. Expected frequency of perinatal transmission is 5.8%, indicating only one third of the cases in this cohort were reported to public health authorities.

Retrospective analysis of vertical Hepatitis C exposure and infection in children in Western New York

BACKGROUND

Vertical transmission of hepatitis C virus (HCV) is the primary cause of hepatitis C in the pediatric population. Nonetheless, only a small proportion of HCV-exposed children are tested. This study aimed to measure the proportion of HCV-exposed children tested and infected in Western New York and to identify factors influencing the odds of testing and infection in this population.

METHODS

This was a 11-year retrospective chart review study in which clinical, demographic, and behavioral data for HCV-exposed children and their mothers were collected. This period included year 2019 when a hepatitis C program began promoting early hepatitis C screening among infants born to mothers positive for hepatitis C. PCR-based detection of hepatitis C was used for children under 18 months of age and antibody testing for children above 18 months of age, followed by PCR if the antibody testing was positive. Logistic regression models were used to determine which characteristics associate with testing and infection status.

RESULTS

From a total of 133 children evaluated in clinic for hepatitis C from 2011 to 2021, 96.2% (128/133) were seen from 2019 to 2021. Among the 133 HCV-exposed children in our sample, 72.1% (96/133) were tested for HCV, 62.4% (83/133) were tested by PCR, 9.0% (12/133) tested by antibody, and 5.2% (5/95) of those tested were infected. Only one child out of 12 was positive for hepatitis C antibody yet, subsequent PCR testing was negative in this child. Among all five hepatitis C infected children, four were diagnosed with neonatal abstinence syndrome, five had maternal history of illicit drug use, one had maternal history of HIV infection, and all of them were identified after the hepatitis C program open in 2019. The odds of a child being tested were lower for those accompanied by their biological mother at their clinic visit (odds ratio, 0.16; 95% CI, 0.06-0.45).

CONCLUSIONS

Screening programs on hepatitis C vertical transmission improved detection of hepatitis C among exposed children. The proportion of children born to mothers with hepatitis C in Western New York that were positive for hepatitis C was 5.2%, suggesting that similar proportion of exposed infants born before 2019 were lost for follow up.

Overall Vertical Transmission of Hepatitis C Virus, Transmission Net of Clearance, and Timing of Transmission

BACKGROUND

It is widely accepted that the risk of hepatitis C virus (HCV) vertical transmission (VT) is 5%-6% in monoinfected women, and that 25%-40% of HCV infection clears spontaneously within 5 years. However, there is no consensus on how VT rates should be estimated, and there is a lack of information on VT rates "net" of clearance.

METHODS

We reanalyzed data on 1749 children in 3 prospective cohorts to obtain coherent estimates of overall VT rate and VT rates net of clearance at different ages. Clearance rates were used to impute the proportion of uninfected children who had been infected and then cleared before testing negative. The proportion of transmission early in utero, late in utero, and at delivery was estimated from data on the proportion of HCV RNA positive within 3 days of birth, and differences between elective cesarean and nonelective cesarean deliveries.

RESULTS

Overall VT rates were 7.2% (95% credible interval [CrI], 5.6%-8.9%) in mothers who were human immunodeficiency virus (HIV) negative and 12.1% (95% CrI, 8.6%-16.8%) in HIV-coinfected women. The corresponding rates net of clearance at 5 years were 2.4% (95% CrI, 1.1%-4.1%), and 4.1% (95% CrI, 1.7%-7.3%). We estimated that 24.8% (95% CrI, 12.1%-40.8%) of infections occur early in utero, 66.0% (95% CrI, 42.5%-83.3%) later in utero, and 9.3% (95% CrI, 0.5%-30.6%) during delivery.

CONCLUSIONS

Overall VT rates are about 24% higher than previously assumed, but the risk of infection persisting beyond age 5 years is about 38% lower. The results can inform design of trials of interventions to prevent or treat pediatric HCV infection, and strategies to manage children exposed in utero.

Hepatitis B and C in Pregnancy and Children: A Canadian Perspective

In 2016, the World Health Organization released a plan to eliminate viral hepatitis as a public health threat by 2030. For Canada to achieve the recommended decreases in HBV- and HCV-related new diagnoses and deaths, an increase in services is urgently required. Identifying those at risk of, or who have acquired HBV and HCV, remains a challenge, especially with the emergence of new priority populations such as pregnant persons and children. Importantly, prenatal, and pediatric care are times when individuals are often already engaged with the healthcare system, leading to the potential for opportunistic or co-localized care and interventions. At present, Canada may not be maximizing all available virologic tools that could lead to increases in prevention, identification, improved management, or even cure. Here, we describe the continuum of care that includes preconception, prenatal, postpartum, and pediatric stages; and identify current global and Canadian recommendations, findings, and opportunities for improvement.

Defer no more: advances in the treatment and prevention of chronic hepatitis C virus infection in children

PURPOSE OF REVIEW

Direct-acting antiviral (DAA) regimens targeting hepatitis C virus (HCV) are now approved for young children. This review examines recent DAA experience in children, current treatment recommendations and challenges, and potential treatment-as-prevention strategies.

RECENT FINDINGS

In 2021, the US FDA extended approval of two pan-genotypic DAA regimens, glecaprevir/pibrentasvir and sofosbuvir/velpatasvir, to children as young as age 3 years based on high success rates and reassuring safety profiles in registry trials. Similar performance has been replicated with real-world DAA use in thousands of adolescents and in limited reports of children with high-risk conditions, including cirrhosis, cancer, thalassemia and HIV-coinfection. Treatment without delay is now recommended in the USA for viremic children aged 3 years and up to prevent disease progression and future spread. To date, treatment expansion is limited by high rates of undiagnosed paediatric infection. Universal prenatal screening will aid identification of perinatally exposed newborns, but new strategies are needed to boost testing of exposed infants and at-risk adolescents. Postpartum treatment programmes can prevent subsequent vertical transmission but are hampered by low rates of linkage to care and treatment completion. These challenges may be avoided by DAA use in pregnancy, and this warrants continued study.

SUMMARY

Paediatric HCV is now readily curable. Substantial clinical and public health effort is required to ensure widespread uptake of this therapeutic breakthrough.